Provider First Line Business Practice Location Address: 
5510 TIMBERLANE ST APT D7
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
EAST LANSING
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
48823-3784
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
419-410-2240
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/04/2014